When a surgeon is not a surgeon

While most of us assume medical procedures are tightly controlled, one segment of the industry has almost entirely escaped regulation. William Verity takes a look at the fields of cosmetic surgery and skin cancer treatments.

This article represents part of a largerBackground Briefinginvestigation. Listen to William Verity's full report on Sunday at 8.05 am or use the podcast links above after broadcast.

It was only because Janelle Trigg had some time on her hands that she decided to follow the advice of her friend and get her nose checked out.

It was small. A tiny bit of white skin on the side of her nose. Probably nothing to be worried about. As it turns out, it was indeed nothing to worry about, at least in the medical sense.

Except the treatment she received at a skin cancer clinic turned out to be something to worry about— it was a catastrophe that has scarred her for life, and has forced her to embark on a remarkable four-year fight for justice.

By her own admission, her nose carries on its tip, ‘a great indentation like a skate park’, even after she spent $7,500 of her own money trying to fix it.

‘I don’t think it will ever be over. I’m going to have to live with this for the rest of my life,’ she says.

What makes her case important is the system it illustrates.

Medical mistakes, complications and botch-ups are to be expected occasionally. Where medical procedures result in harm to patients, we have regulations and a legal system that will pick them up. Right?

Wrong.

Few people realise that there are two areas of medicine—skin cancer treatment and cosmetic medicine—that are largely unregulated and where people carrying out surgical procedures aren’t required to have specialist skills.

Carla*, a 22-year-old university student, had wanted a breast augmentation since she was 15, so she saved up the money and went under the knife last year.

As is common with these procedures, the operation was performed in the doctor’s rooms, without the full protection of a day care centre or private hospital, and under so-called ‘twilight’ anaesthetic.

These are powerful drugs that cause drowsiness and amnesia and thus eradicate all memory of pain.

Carla cannot remember anything from the week after her operation. She has no memory of complaining that her implants were too small, nor going through a second procedure (performed a day later) where her original implants were replaced by much larger ones.

She does, however, remember the moment a week later when she looked at herself in the mirror, and she remembers the $10,000 bill.

Carla also remembers the rash that spread across the top half of her body about three weeks later, and the advice from the cosmetic surgeon to let it die down.

The doctor at her local hospital told her if she hadn’t come in, she could have died. The rash was cellulitis—a bacterial infection.

‘At first I thought anyone who practised plastic surgery was a plastic surgeon,’ Carla said.

'It wasn’t until I was in hospital that I was informed by nurses that there is a difference between cosmetic surgeons and plastic surgeons. A cosmetic surgeon can be any doctor.’

In the netherworld of unregulated medicine a surgeon is not necessarily a surgeon, a specialist is not necessarily a specialist and no one—not the industry, not the regulator and not the lawyers—appears able to act.

Several reports, the first of which was published in 1999, have recommended changes to the cosmetic industry, but so far almost nothing has changed.

Professor Merrilyn Walton was head of the Health Care Complaints Commission in NSW in the 1990s and author of the 1999 report.

What worries her most about cosmetic surgery and skin cancer surgery is that invasive procedures are being done in doctors’ rooms, outside the normal surgical environment.

‘Sixteen years later we have people having procedures done in rooms by unqualified surgeons, and we have had instances of people being transferred to major hospitals as a result of the difficulty,’ she said.

‘At the moment, of course, any doctor, whether they're a specialist doctor or not, can perform invasive procedures.

‘There's absolutely nothing to stop them.

‘They're able to do this because they're not required to maintain any standards in relation to the equipment or the rooms under which they do these procedures.’

Even Dr Joanna Flynn, the chair of the regulatory body, the Medical Board of Australia, admits the situation is far from satisfactory.

On the subject of skin cancer ‘specialists’ who may only have the most basic medical qualification, a bachelor of medicine, she says:

‘It’s on our list of things to do, but we haven’t addressed it yet.’

As far as similarly unqualified cosmetic surgeons are concerned, the board has recently issued a set of proposed guidelines.

They include measures to enforce a cooling off period for people who have booked in for procedures; psychological assessments for minors; and clear guidance on informed consent.

However, there is no proposed change for the two biggest issues: the regulations around operating in doctors’ rooms, and the question of training.

It will still be possible for anyone with no extra surgical training or experience to call themselves a cosmetic surgeon.

‘In order for that change to be made, it would require support from Australia’s health ministers and a change in the national law,’ Dr Flynn said.

On that, there have already been 16 years of inertia.

*Carla's name has been changed to protect her identity.

Editor’s note: The Background Briefing story transcript has been clarified in relation to the death of Lauren James in 2007. Lauren died after undergoing a straight forward cosmetic surgery procedure, liposuction, but in her case the procedure was carried out by a fully qualified plastic surgeon.

Transcript

Carla: Well, I've always wanted to have a breast augmentation since I was about 15, and I thought why not, I had saved up money for it and I thought I'd give it a go.

William Verity: Carla is a 22-year-old university student who late last year decided to have the breast enlargement procedure she'd been thinking about for years. She was already familiar with cosmetic surgery.

Carla: I have had my nose done, I've had a rhinoplasty at the same clinic with a different doctor, and that all went smoothly. I had friends who had gone there and gotten a breast augmentation and it all went well, so I thought I'll give them a go.

William Verity: After several consultations, Carla went in for her surgery. She was sedated with so-called 'twilight' anaesthetic that works by wiping all memory of pain. Carla says she has no memory of the whole week following the operation.

Carla: My first memory would be probably a few days later when my sister was actually in my room and was telling me that not only had I had one breast augmentation, I had two. I had complained apparently after the first surgery that they were too small, and the next day they got me in less than 24 hours later and redid the surgery and put bigger implants in, but I don't remember any of that. They were way too big for me, I didn't like how they were sitting, and I could tell that my scars were in the wrong spot. They were supposed to be in the crease and they weren't, they were much higher up. Just the way they sat, they just didn't look right on me.

William Verity: About three weeks later, she noticed a rash around her scar.

Carla: Twenty four hours later, that rash had spread all across my breasts and I thought I'd better go in again. They put me on an IV for about 20 minutes and gave me some antibiotics and I went home. That night, the rash had spread all across my back and I went to the hospital. There they diagnosed me with cellulitis.

William Verity: Cellulitis is a skin infection most commonly caused by bacteria infecting a bite or a wound. The rash spreads quickly and if untreated can be fatal.

Carla: I was back to square one and I had lost breast tissue because of the infection as well, so I was even flatter than what I began with, and it was just a very traumatic experience. If I could speak to myself five months ago, I would have talked myself completely out of doing it and just been happy with the way I was because it was a very traumatic experience. After having cellulitis and being in hospital and having to lose the implants, I became very depressed. I didn't want to go out, I just was upset, I had fallen behind in my university studies, it just really affected my life. Something so small that I thought would be great, how it changed my life so dramatically from a very outgoing girl. All my friends noticed, wow, what happened, you're not coming out any more, you don't want to even just go for a coffee. I just didn't want to leave my room, I was just traumatised by the experience.

William Verity: Carla assumed that a doctor using the title 'cosmetic surgeon' had some expertise in the field and, like other types of surgeons, had additional qualifications to conduct surgery. On both counts, she was wrong.

Today on Background Briefing, why undergoing surgery outside of a hospital or specialist setting can be a risky business, and why our health regulators and lawyers seem powerless to act against specialists who are not specialists, and surgeons who are not surgically trained.

The lack of regulation around the burgeoning cosmetic surgery industry has been a concern for both regulators and practitioners for years, but little if anything has been done in terms of safeguards. The Medical Board of Australia has drawn up a new set of proposed guidelines, which are currently out for public comment. Again, they fall short of the regulation that many in the industry are demanding.

And it's not just cosmetic surgery, like breast augmentation, tummy tucks, liposuction and so on. Even when it comes to skin cancer clinics found on suburban high streets around the country, it's a case of buyer beware.

Last year, NSW state MP Gareth Ward took up the story of one of his constituents, Janelle Trigg, raising her case in Parliament.

GarethWard: However, today I come to this House as a last resort to tell the story of one of my constituents who deserves to have her story told. Janelle Trigg is a perfectly normal, hard working woman whose experience with the health system is anything but ordinary. On 5 July 2011, Janelle attended Wollongong Skin Cancer Clinic to see to a white spot of skin that had appeared on the bridge of her nose. The doctor concerned took a biopsy for further investigation.

William Verity: Here, Janelle Trigg takes up the story.

Janelle Trigg: He said as I was leaving, 'You'll probably never hear from me,' and I thought that would be right, it's only a little white piece, it's nothing. So off I went, thinking nothing of it. A week and a half later, I got a phone call from Wollongong Skin Cancer Clinic and I said, 'What are you ringing me for?' She said, 'You've got to come back in.' And I said, 'What for?' She said, 'You've got cancer.' I said, 'What?!' I was amazed because I've got olive skin and I thought, no, never. Anyway, I was terribly upset and I went straight back in and I got into his office. I said, 'What's going on?' He said, 'It's pre-cancerous.' And I said, 'Well, what does pre-cancerous mean?' And he said, 'It's got the potential of turning into cancer.'

William Verity: The doctor told Janelle the white spot on her nose needed to be removed.

Janelle Trigg: So he gave me the confidence that he knew what he was doing and I thought it would be absolutely okay, so he got me to sign papers and then hit me with an ice gun, which then in turn caused a huge big indentation in my nose like a skate park.

William Verity: The damage from the ice gun was worsened when the doctor put a stitch in her nose, and it became infected. Janelle Trigg, like Carla, thought she was going to see a specialist. They didn't know that neither skin cancer nor cosmetic medicine is officially recognised as a specialty.

The national body that oversees the medical profession is the Medical Board of Australia, chaired by Dr Joanna Flynn.

Joanna Flynn: We have a field of specialties which includes plastic surgery as a recognised speciality, and general surgery as a recognised speciality, and we have general practice which is essentially comprehensive family medicine. But skin cancer medicine per se and cosmetic medicine are not recognised specialities. Now, what that means is that somebody can call themselves a skin cancer specialist or call themselves a cosmetic surgeon or cosmetic physician without coming into a regulatory framework governed by the Medical Board.

William Verity: We'll hear more from Dr Joanna Flynn later in the program.

For Janelle Trigg, this was the start of a long and expensive journey to seek redress for the damage done to her face at the Wollongong Skin Cancer clinic. Four years on, her fight is far from over.

Journalist: Nine people are seeking compensation from a Wollongong GP after on-going skin cancer removal procedures which they say went horribly wrong. They want new regulations…

James Govan: I'm handling a number claims against a particular doctor, a local doctor, with Janelle Trigg who is the main claimant in the sense that she has organised this group together and has mobilised a class action essentially.

(Editor's note: As of 15 April 2015 there were 16 claimants in this group action)

William Verity: James Govan is in his Wollongong office with Janelle Trigg. He first met Janelle at a low point in her life; she had a deep scar at the tip of her nose and she wanted the Medical Board to take professional action taken against the doctor. Janelle explains what she did before contacting her lawyer.

Janelle Trigg: The first thing I did I went to the Medical Board. I rang them in the beginning and I told them what had happened to me. I was devastated, because I have to get up every morning and look at myself, and I was crying over the phone. So I wrote to them, I put it all in writing, exactly what I had to do. And they investigated him and on two charges they found him not to be negligent.

William Verity: The Medical Board found Dr Jeremy Reader had done nothing wrong.

Janelle Trigg: And this is what is so devastating. They allowed him to keep practising.

William Verity: Janelle Trigg went to James Govan after failing to get any joy from the health regulators. But her legal attempts at compensation also failed.

Janelle Trigg: We got to a point after three years and they wouldn't settle, so in the end James said the only thing you can do is go and see your local member, and that's exactly what I did do.

William Verity: After her MP Gareth Ward first raised the matter in parliament, many more patients came forward with similar experiences. So he raised it again.

Gareth Ward: The House will recall that I have previously raised the plight of Janelle Trigg and her encounter with Dr Jeremy Reader, who operates the Wollongong Skin Cancer Clinic. Since giving a voice to Janelle in this place, more of Dr Reader's patients have come forward to tell their story of a man who is manifestly unqualified to undertake certain surgery, with disastrous results, the results of which I've seen firsthand. I wish to use parliamentary privilege this morning to relay some of those details to the House in the hope that giving a voice to those who feel angry and fundamentally and unnecessarily let down by someone who is charged with the care of his patients.

William Verity: With a number of cases against the same doctor, a pattern of bad outcomes was established.

Lorraine Long: It's got to be a pattern that will actually bring it to the authority's attention, because then there is a pattern that is being repeated. But those authorities have got to be looking at more than one case together, they've got to be looking at a doctor's practice.

William Verity: Lorraine Long set up the Medical Error Action Group nearly 20 years ago after her mother died in unexplained circumstances in a Melbourne hospital. Since then, about 26,000 cases have been logged by the group. Lorraine Long says the system is heavily weighted towards protecting medical practitioners.

Lorraine Long: It's what drives people around the bend and it's what causes unnecessary anger, and why patients and bereaved families become very, very cranky. They are discarded by their representatives, their members of Parliament, the Health Department, the hospital lawyers get on to you, the doctors' lawyers get on to you, and in the end people are exhausted, reach an exhaustion point and they can't go on any longer. It's very hard to call a doctor to account. I mean, they are the professionals, and supposedly patients are not.

The surgery that's being conducted in some GPs' rooms is not of a standard that's acceptable. One of the areas is that a number of people end up with infections and it's the infection which sends them back to the doctor. If that infection is not addressed, that's what they end up in hospital with. I am amazed at the type of surgery being done in GPs rooms when I believe, and I'm not a doctor, but I believe it should be conducted in a hospital setting for sterilisation reasons and proper equipment there for resuscitation.

William Verity: It's not just disgruntled patients who are arguing for change. As far back as 1999, a report for the NSW Health Minister put the case for change. It recommended an accreditation scheme for doctors conducting cosmetic work and a requirement that anyone performing invasive procedures must be surgically trained. Those recommendations were not implemented.

The lead author was Merrilyn Walton, Professor of Medical Education and Patient Safety at the University of Sydney. Professor Walton says a lack of available patient data continues to obscure the true extent of the problem.

Merrilyn Walton: Because there's no requirement on any doctor in their private rooms to keep data or to report it to anyone. Even though the college of surgeons does require its members to keep their outcome data, but that's for the college and it's only disclosed to the members themselves. But there's no requirement at a national or state level that we know of any adverse events in doctors' private rooms.

William Verity: Is that a satisfactory situation?

Merrilyn Walton: No, of course not. The beauty of getting data about adverse events is you can analyse it and see where the problems are. So you can do what we call a root cause analysis and then attack the problem, rather than attacking everything, which might only really address 5%.

William Verity: Cosmetic surgery is lucrative and Merrilyn Walton says any doctor or GP can do it, with virtual no training.

William Verity: Would it be possible for a GP to simply go ahead with cosmetic surgery without any credentials at all, aside from being a GP?

Merrilyn Walton: Yes, of course. They probably go to a weekend course, they would certainly need to undertake some observational training. Or buddy with…they probably know cosmetic surgeons and they ask if they can go and assist them and do a couple with them. But that is not sufficient. To me it's just so unethical to do that; see one, do one, and then teach one. That doesn't deal with cosmetic surgery.

William Verity: What's the financial motivation for a GP to do that?

Merrilyn Walton: There's huge money in cosmetic surgery. GPs who do cosmetic surgery will make far beyond what they would make as general practitioners. So it's half a million or more a year compared to what a general practitioner earns. They charge thousands of dollars for these procedures.

William Verity: Although hard data is hard to come by, there is little doubt that the field of cosmetic surgery has grown massively in the last two decades.

Merrilyn Walton: When cosmetic surgery developed, I think people just saw it as a few cowboys out there doing their own thing. But it has become so pervasive now within medicine. It has developed separately. So the same requirements we have for doctors in hospitals or specialists, doesn't apply to people who do cosmetic surgery in their rooms. So they are being left to follow the financial path, and even treat cosmetic surgery as a product to be sold, to be marketed. And that's not medicine.

Journalist: A coroner has found three doctors at a plastic surgery clinic failed to properly care for a 26-year-old woman who died after having liposuction. The family of the patient is now calling for tougher regulation of the cosmetic industry.

Journalist: Lauren James's death was preventable had she received better post-operative care.

Man: She was just a great girl and we miss her so much. And no family should have to go through things like this, it's horrible.

Journalist: At 26 she was fit and healthy, until she had liposuction at this Caulfield North plastic surgery clinic. Three days later she collapsed and died. Her complaints of severe pain were ignored…

(Editor’s note: In this case Lauren James died following a cosmetic procedure which was carried out by a fully qualified plastic surgeon. Read the coroner’s findings)

William Verity: Lauren James died in Melbourne in 2007. While deaths from cosmetic surgery are rare and well publicised, less catastrophic mistakes are common enough. They seldom come to public attention for a number of reasons; patients may see little to gain in making an official complaint. And if they manage to reach a legal settlement, they almost always have to sign an agreement to keep the terms confidential.

Kathryn Booth is the head of the national medical negligence practice for Maurice Blackburn Lawyers. She is highly critical of the way national laws have changed.

Kathryn Booth: First of all, in 2003 the laws around Australia were changed so that you could only sue a hospital or doctor, including a cosmetic surgeon, if you were left with quite a significant injury. Each state is different, but if you take Victoria for example, you have to have a significant injury to sue a doctor, and in NSW you have to have a 15% injury of the most serious kind, whatever that actually means, but in any event it means you have got to be left with quite a disability from the outcome.

These laws have been a real bonus for the cosmetic surgeons because it's very hard to sue them unless you're left with a permanent disability of some degree. So despite the fact that they are carrying out quite entrepreneurial medicine and they might be advertising quite highly for patients, they are well protected in the civil law by the fact that you can't sue a doctor unless you're left with a fair degree of disability.

William Verity: Kathryn Booth is also critical of the Australian Health Practitioner Regulation Agency, or AHPRA, set up in 2010 as the investigative arm of the Medical Board of Australia. The action taken in the matter of Lauren James is a case in point.

Kathryn Booth: The next area of course is AHPRA, they can be quite slow in getting an outcome in respect to the cosmetic surgery cases or doctors. We recently had in Melbourne a case that took eight years for it to get to the end of the AHPRA process for looking at the conduct of the doctors, it took eight years, and that's where someone had died from liposuction. So it took eight years to get to the final decision against these particular doctors as to what the penalty should be. And in the end it was that they should attend some re-education, which coming eight years later seems a little bit late. In the meantime, the consumers are still going to those particular doctors.

William Verity: How well informed are patients when they go into this? How well informed are they about the qualifications of the practitioner?

Kathryn Booth: It's a problem that not many patients are fully aware of the qualifications of the doctor because they can call themselves a cosmetic surgeon or a cosmetic surgery specialist and yet they haven't got the qualifications, for example, of a surgeon, such as a plastic surgeon.

William Verity: How often are those poor performers either restricted to do the more simple procedures or, in more extreme cases, struck off, deregistered altogether? How often does that happen?

Kathryn Booth: That's pretty rare that you see a doctor struck off. And, without going into details, there have been a couple of infamous cases in Victoria where it has taken a very, very long time for anything to be done that stops the doctor practicing.

William Verity: That's Kathryn Booth, head of the national medical negligence practice for Maurice Blackburn Lawyers.

I'm William Verity, and today on Background Briefing, why undergoing surgery outside of a hospital or specialist setting can be a risky business, and why our health regulators and lawyers seem powerless to act against specialists who are not specialists, and surgeons who are not surgically trained.

It would be too easy to write off all cosmetic surgeons as greedy and under-qualified. The reality is that the overwhelming majority provide a high level of service and have satisfied customers. Their field is blighted by a small number of practitioners who generate the majority of complaints. Everybody agrees more needs to be done, but no-one seems able to do anything. Perhaps one reason is the entrenched turf war waged between two groups of surgeons.

I'm in the expensive suburb of Double Bay in Sydney where money for beauty therapies is not in short supply. I'm here to meet Dr Russell Knudsen, a specialist in hair grafting, and a founder member of the Australasian College of Cosmetic Surgery.

Russell Knudsen: My practice is full-time dealing with hair loss, so on the medical side we consult and prescribe drugs like other doctors would. On the surgical side we perform hair transplantation surgery, which is an outpatient procedure that involves taking grafts of hair from the back of the patient's own head and transplanting it typically to the top or front of the head, mostly for male pattern baldness, but also for scars, burns scars, traumatic scars and other causes of hair loss as well.

William Verity: Okay, and tell me a little bit about your training.

Russell Knudsen: I started in the surgical training program in hospital, then went out into general practice, and then became interested in this area and apprenticed myself to one of the other surgeons in the area, because in 1982 there was no formal training in any sense for this sub-specialty interest.

William Verity: To this day, there is still no officially recognised training, despite the college established nearly 20 years ago by Dr Knudsen and others.

Russell Knudsen: The College of Cosmetic Surgery was instituted in 1998 to address the idea that we should have formal training and formal qualifications for people that were going to be serious about the practice of cosmetic medicine and cosmetic surgery, because it's one thing to dabble, it's another thing to be doing it as the majority of your practice.

William Verity: The Medical Board of Australia doesn't recognise the college, arguing that any medical specialty must address a disease, and cosmetic surgery does not. This also explains why cosmetic surgery is not covered by Medicare, and that's a major reason both for the lack of data and the lack of government oversight. It's also an incentive to attract business by offering cut-price services.

Russell Knudsen: Given that there is no Medicare rebate for cosmetic procedures, that means that basically any doctor with a medical degree can advertise that he could perform such a procedure. And given that many of the procedures are low-invasive and can be performed in the doctor's own private rooms, there is no requirement for supervision by advisory committees that would be appropriate in a private hospital setting or a public hospital setting. So essentially we have to self-regulate in that situation.

William Verity: Can you give me some examples of egregious practice that you are aware of, of cowboys in the field?

Russell Knudsen: The thing about it is people need to remember that surgical procedures require surgical skill, and unfortunately because, again, the area doesn't have a price regulation that may be set by Medicare, people can advertise based on price. If patients are lulled into this false sense of security that anybody who is advertising is obviously competent, so therefore they will go the person that offers the lowest price, that can get them into a lot of trouble.

William Verity: One of the big differences of cosmetic surgery is that no referral is necessary. Patients self-refer, so there is much greater ethical pressure on practitioners to advertise truthfully and to gain ethical, informed consent.

The Australasian College of Cosmetic Surgery has fought since 1998 for formal recognition of its training program and ethical standards. This has been opposed all along by plastic surgeons, who must undergo rigorous post-graduate surgical training for up to a decade before they are fully qualified.

Professor Peter Haertsch is an outspoken critic of the College of Cosmetic Surgery.

Peter Haertsch: When you look at the Australian College of Cosmetic Surgeons, which is not formally recognised, you will find that a lot of them are simply general practitioners. The Australian College of Cosmetic Surgeons would say they have got a training program, that training program involves going and watching a number of all manner of cosmetic procedures, and going to lectures and watching videos and reading texts. But there is nothing which takes the place of hands-on experience.

William Verity: Professor Peter Haertsch is one of Australia's most respected plastic surgeons. He heads the burns surgery unit at Concord Hospital in Sydney.

I spoke to him in one of the hospital operating theatres where he performs his operations and asked him about his view of the rules governing cosmetic surgery.

Peter Haertsch: Well, there don't appear to be any ramifications because there aren't any guidelines and there aren't any…there's no regulation. Anybody can do these things. As an MBBS, bachelor of medicine and bachelor of surgery, there is nothing to stop you from actually doing anything you like.

And I would take issue with the term 'specialist GP' for the simple reason that they are doing a surgical procedure and they are not surgically trained. People who are surgically trained have a very clear understanding of the basic sciences, they have a very clear understanding of wound healing, and, particularly in the plastic surgical field, a very clear understanding of how to handle tissues. The real problem with people, they get into trouble and they don't know how to treat the complications.

What I'd like to see change in respect to the so-called turf war, cosmetic surgery versus plastic surgery, what I'd like to see is that all the people performing cosmetic surgery are in fact surgically trained. To get to that point you would in fact have demonstrated that you do have an understanding of the basic sciences, that you have gone through a period of apprenticeship, so to speak, five years it is, whereby you will have demonstrated that you understand wound handling, tissue handling and that you've seen a fair amount of surgery.

William Verity: So where is the regulator in all this? It turns out the Medical Board of Australia also sees a problem with cosmetic surgery and has drawn up a set of guidelines for the industry. They were released last month and are currently out for consultation.

The list is very similar to the guidelines recommended over 15 years ago for NSW. They suggest a compulsory seven-day cooling-off period for adults after booking a procedure; a three-month cooling-off period for minors; explicit guidance on what constitutes informed consent; detailed written information about costs, and limits to what procedures can be performed in rooms.

Perhaps the most striking aspect is what is not there. There is nothing to address the need for training, nor qualifications. Nor is there any talk of defining the term 'surgeon'.

Here's Dr Joanna Flynn, chair of the Medical Board of Australia.

Joanna Flynn: The sort of things that we were asked to look at were things like whether there should be cooling-off periods; what sorts of particular arrangements should apply for people under the age of 18 because they are potentially more vulnerable; issues around appropriate consent. We have got to remember that cosmetic procedures are not in a sense necessary in the same way that other procedures are and so there needs to be a higher level of consent. And also some appropriate statements about financial relationships for cosmetic procedures, which can be quite expensive.

William Verity: Okay, talk to me about the kind of qualifications that are necessary in order to become a cosmetic surgeon.

Joanna Flynn: You said at the outset that you were talking about two sorts of medicine—skin cancer medicine and cosmetic medicine—and in fact neither of those are recognised specialities in Australia. Now, what that means is that somebody can call themselves a skin cancer specialist or call themselves a cosmetic surgeon or cosmetic physician without coming into a regulatory framework governed by the Medical Board.

William Verity: In your view, is that satisfactory?

Joanna Flynn: It's a difficult situation, William, because many people develop subsets of skills and they're very good at them, but they may not be a comprehensive set of skills in a particular field that needs to be recognised as a speciality, like cardiology or renal medicine or orthopaedic surgery. So, cosmetic medicine and surgery has sought to be recognised as a specialty but they haven't actually met the criteria that are necessary for them to be able to be incorporated into our regulatory scheme as a recognised speciality. So it's a bit of a no-win situation at the moment.

William Verity: The first thing I understand from that is actually the only regulation about calling myself a skin cancer specialist is around the money, that I with no medical degree could actually call myself a skin cancer specialist and set up shop, theoretically, I'm not saying that this happens. But theoretically I could put a sign outside my shop and say 'Skin Cancer Specialist', or even 'Skin Cancer Surgeon', and I would not be breaking any regulations, I would not be breaking the law.

Joanna Flynn: If you were creating an expectation in the people who came to see you that you were a doctor, that is a registered medical practitioner, you could be prosecuted for holding yourself out as a doctor. But once you have got a medical degree, you could certainly use those titles without any particular additional qualification.

William Verity: So this brings us to the title 'surgeon'. For many people…I think people make an assumption that a surgeon is someone with a medical degree plus some postgraduate specialist surgical knowledge. Is that the case?

Joanna Flynn: That is what most people would think and it's true of most surgeons, but strictly speaking somebody could call themselves a surgeon. They can't call themselves a specialist surgeon. This is some of the intrinsic weaknesses I think in our current system of classification of specialties, and so there are some titles which people would think were protected which are not strictly in law protected.

William Verity: So that would obviously include someone with a general medical degree can call themselves a cosmetic surgeon and they do and they are not breaking any law. If a complaint came to you that this person is performing surgery, calling themselves a surgeon but they only have a baseline medical degree, there is actually nothing you could do about that.

Joanna Flynn: That's true, whereas in fact 'dermatologist' is a protected title so people can't call themselves a dermatologist unless they are recognised, qualified and specialist dermatologists. But people could call themselves a cosmetic surgeon or a cosmetic physician without that additional qualification.

William Verity: Is that something that you would like to see changed, specifically the word 'surgeon' I suppose?

Joanna Flynn: I think we may be moving to a time when the title 'surgeon' should be restricted to qualified, registered, specialist surgeons who have been through recognised training, usually with the Royal Australian College of Surgeons or equivalent overseas bodies. But in order for that change to be made it would require support from Australia's health ministers and change in our basic legislation, the national law governing health practitioner regulation.

William Verity: So presumably some kind of up-swell of public opinion to say this is not good enough?

Joanna Flynn: That's right.

William Verity: Dr Joanna Flynn, Chair of the Medical Board of Australia.

So it seems that little is likely to change in the foreseeable future. The best advice from all concerned is that it's up to the individual patient—not the government nor the medical profession—to do the research and identify the poor performers.

This, for some, is simply not good enough. Here's MP Gareth Ward in Parliament, representing the views of a number of his constituents currently mounting legal action against Wollongong skin cancer doctor Jeremy Reader.

Gareth Ward: It is not unreasonable to suggest that those attending a skin cancer clinic may be of the view that they are receiving some form of specialist treatment. Madam Speaker, clearly that is not the case. Of course doctors provide medical advice, but in light of the cases I have raised and met, it is my very strong view that consumer protection measures are warranted in this space and, Madam Speaker, I would argue urgently warranted in this space, given the conditions and the experiences of the constituents of mine that I mention here in this place today.

Madam Speaker, I don't know Dr Reader, but I have seen the results of his work firsthand. I raise these cases in Parliament today in the hope that our community is made aware of his work and that those who have suffered can be assured that their cases are not only heard, but taken seriously by me and will be investigated.

William Verity: One of those constituents, Janelle Trigg, is currently recovering from the latest in a series of operations to fix the scar on her nose.

Janelle Trigg: I just thought skin cancer clinics were…you know, only specialists working in there. I mean, the public haven't been educated, I was never educated prior to this. And then in this journey I have been to a dermatologist since then and he told me that he would have treated it with a vitamin A cream, that he would never have even touched me. He's seen my biopsy and he said you would never have touched that, he said you would have treated that with a vitamin A cream. So you can imagine how I feel about that. Here I am today and I'm four years later, $7,500 out of pocket, I have seen numerous doctors, I'm up to my third operation, and I should have been treated with a vitamin A cream.

Four years after Janelle Trigg's complaint was initially dismissed, the state regulator, the Medical Council of NSW, has now suspended Dr Reader from practising medicine.

A statement released last month from the Medical Council said the 'condition was imposed with Dr Reader's consent' and that it was 'a temporary and indefinite measure, pending the outcome of other formal inquiries or investigations'. In the meantime, Janelle Trigg gets up every morning and looks at that nose in the mirror.

Janelle Trigg: I look at that nose and I think there's nothing that I can buy or fix it. And all I do now is I look at other people's noses and I look at the smoothness on the nose, and that's all I do every day. I look at someone's nose and I think, geez, that's nice, they've got a nice smooth finish on their nose, and I've got this big ditch. Yes, it has affected me. I don't feel as confident in myself anymore. I work in the schools with the kids and they'll go, 'What's wrong with your nose, Miss?' Sometimes you just don't want to tell the story because it goes on for so long. The kids haven't have all day to stand there. So yeah, it's…you know, I try to get on with it but it has knocked me around.

William Verity: Background Briefing's co-ordinating producer is Linda McGinness, research by Anna Whitfeld and Lawrence Bull, technical production by Simon Branthwaite, the executive producer is Chris Bullock, and I'm William Verity.